Provider Demographics
NPI:1841683943
Name:UPLIFTING LIVES CLINIC OF ARIZONA, LLC
Entity type:Organization
Organization Name:UPLIFTING LIVES CLINIC OF ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:CAROLYN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-670-6077
Mailing Address - Street 1:5150 N 99TH AVE
Mailing Address - Street 2:APT. 1097
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3001
Mailing Address - Country:US
Mailing Address - Phone:602-670-6077
Mailing Address - Fax:
Practice Address - Street 1:5150 N 99TH AVE
Practice Address - Street 2:APT. 1097
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3001
Practice Address - Country:US
Practice Address - Phone:602-670-6077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)